A while back, a first-year med student asked me if I think physicians should wear white coats. There’s a debate about it, she mentioned. Indeed, in the spring of 2009 the AMA considered an unenforceable mandate that physicians in the U.S. not wear white coats. The news was getting around that doctors spread infection from one patient to the next by our garments.

My thoughts on this have always been clear. “Yes,” I answered. “But they’ve got to be clean white coats.”

This week I came upon two stories that led me to pick up the thread on the white coat debate. First, a recent post from the Singing Pen of Doctor Jen, by Jennifer Middleton MD, MPH, who writes from western PA:

We physicians might make assumptions about what patients want us to look like, but what does the evidence say?

A cross-sectional survey in Tennessee a few years ago found that patients prefer family physicians who wear white coats (1). Another study in a South Carolina internal medicine office found that patients “overwhelmingly” preferred physicians in white coats (2). A Northeast Ohio OB residency found similarly; patients preferred a white coat and professional dress to scrubs (3). A quick PubMed search pulls up the same theme over and over: the patients studied have more trust in, and comfort with, physicians who wear white coats…(hyperlinks inserted by ES)

Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know.

Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future.

As a doctor, I think physicians should wear white coats for several reasons. First, the white coat reminds the wearer that medicine is a special kind of profession, that doctors have extraordinary obligations to patients. Second, the white coat recalls medicine’s basis in science, from which we wouldn’t want to stray too far. Third, it’s to protect ourselves: going home to dinner with your family, loaded with hospital germs, is just not smart.

As a patient, I like it when my doctors where a white coat. It’s reassuring in a primitive kind of way; it makes me feel like the physician is a real doctor who is capable of taking care of me. But the coat should be clean – every day a fresh one, with extra changes if needed.

Of course there are some circumstances when the white coat is appropriately relegated elsewhere: in places like the OR, in most psychiatrists’ offices and in pediatrics – so as not to scare the children, I once learned although I’m not convinced it would.

It takes a certain effort for a doctor to put on a white coat. When I used to get called back in late at night, or after weekend rounds, I’d occasionally just go straight to the patient’s ward or E.R., without stopping by the room where my coat was kept. That was easier, sure, but when I skipped the white coat I felt as if I weren’t fulfilling my part of the deal: to look and act like a doctor should.

Patients need that, usually. And maybe that’s a hang-up, a superficial wanting, a simple reassurance of authority. But maybe it’s also a sign that you’re serious in your duties as a physician, that you’re not cutting corners, that you will do everything you can to fulfill your obligation to the persons under your care, that you know who you are as the doctor.

Maybe, when younger doctors elect not to wear the white coats, for whatever legitimate reasons, or out of laziness in finding a clean one, it’s really that they don’t want the responsibility the coat conveys.

9 Comments

I appreciate that you have articulated some clear rationale in support of wearing the white coat. If you will permit, I would like to share with you why I would like to see the white coat put to bed, both for the health of patients and for the well-being of physicians.

To me, the white coat represents the authority of physicians. Advertisers have played on this symbol for years to give the impression that if a product is ‘doctor recommended’ it can be trusted and not questioned. While your post frames physician authority as a positive attribute, I see it as a vestige of another time when physicians held a monopoly on information and patients were in the ‘one down’ position.

I wonder if we all wouldn’t be healthier if we realized the fallibility of physicians and that there truly isn’t an ‘otherness’ to being a patient, doctors can be (and often are) patients themselves.

An article in the Lancet (Nov. 2009) discussed the issue of physicians not taking care of their own illnesses or using the services of other physicians, saying, ” Doctors might feel uncomfortable in the role of patient, and fear that others will interpret their need for help as an indicator of their inability to cope.”

Perhaps in these fast-changing times, it is not a bad thing for a physician to be ‘just another professional’, perhaps by acknowledging that a physician can be “a real doctor” with or without white coats, more empathetic patient encounters will be possible.

Perhaps if the props between physicians and patients can be left behind, physicians will also recognize that there is no shame in being a patient themselves.

Once upon a time I could tell the doctor from other office staff by the person who wore the white coat. However, my Oncologist rarely if ever wears a white coat, and his PA and NP always do. Having read the reports that the coats carry germs from patient to patient, now I have a hard time seeing them as anything but something that needs to be laundered. I’m sure that dress clothes and scrubs harbor just as many germs as the white coats, but still, the white coats have lost their meaning and their appeal. Honestly, I don’t care what you wear. If you want to don the white coat, well, whatever floats your boat.

Emmy, I think you’re right that what the oncologist (or any doctor) wears is less important than what they do and think. As for a PA or NP in a white coat, the main thing that concerns me is that it be clean, just as for doctors.

“Of course there are some cir­cum­stances when the white coat is appro­pri­ately rel­e­gated else­where: in places like the OR, in most psy­chi­a­trists’ offices and in pedi­atrics — so as not to scare the children, I once learned although I’m not con­vinced it would.”

I am also not convinced that white coats scare children. The doctors and their white coats usually are long gone before anything unpleasant happens. My child gets scared when she sees latex gloves, as she knows that means a stick of some sort is coming.

I did a double-take when I first met my cardiologist while I was hospitalized with a heart attack. He was extremely tall, dark, handsome, and had very long naturally curly hair (like the “spiral perm” that we women pay a fortune on in the salon!) He wore a striking wild-Hawaiian-parrot print shirt. And no white coat to be seen!

He was also very kind, empathetic, efficient, and an expert in a rarely-seen non-invasive diagnostic procedure called the “hepatojugular response” which immediately helped to confirm his diagnosis of “significant heart disease”. My first impression of him contrasts strongly with the middle-aged white-coated E.R. doc who had earlier sent me home from the same E.R. with a GERD misdiagnosis.

Insightful post. As a young intern I have noticed that the way I am perceived by patients varies whether or not I am wearing my white coat. When I am I tend to get a more congenial “oh you’re my doctor”. When I am not I tend to get “Oh, you’re my doctor, how old are you anyway?”. Whether or not the symbol of the white coat has been diminished by its widespread use by all levels of healthcare personnel (The nursing students where I work wear longer white coats than I do as an intern) is up to debate. However, the fact remains that this is what patients expect to see their doctor wearing.